Form SSA-9303 Notice of Appointment-Please Call Reviewer

Social Security Administration
Office of Quality Performance Review
(Address of Office)
Date:
Beneficiary:
SSN:
(Address)
The Social Security Administration is contacting a few people who have applied for
extra help with Medicare prescription drug plan costs. We are doing a quality review to
make sure we made the correct decision on these applications. We picked (fill-in 1)
name by chance, NOT for any other reason. To make sure we made the correct
decision on (fill-in 2) application, I would like you to telephone me at my office on (fillin 3). For general information about Social Security or to verify that this is an official
communication, you can call our national toll-free number at 1-800-772-1213.
IMPORTANT INFORMATION
You do not have to give us the requested information. If you do provide the information
and your subsidy level is correct, we will not have to contact you to review your eligibility
for at least a year. However, if the information is incorrect or you do not provide the
information, we may contact you to review your eligibility within the next few months.
Such a review of your eligibility could result in your subsidy level increasing, decreasing
or stopping.
We would also like to remind you that if you (and your spouse if married and living
together) have a change in your income, resources or household size you should report
this information to Social Security.
WHAT WILL HAPPEN WHEN YOU CALL
I will identify myself by name as shown at the bottom of this letter. I will ask you some
questions about the information given on (fill-in 4) application for help with Medicare
prescription drug plan costs.
HOW YOU CAN GET READY FOR YOUR CALL
I have enclosed a page that shows the kinds of information you should have ready. I
have checked the things I would like to talk about. If you do not have all of the
information that I am requesting, I can help you get the information you do not have. If
you would like to have a friend or relative help you, please tell that person to be there
when you call.
PLEASE RETURN THE ENCLOSED FORM
I have enclosed an acknowledgement form for you to complete, sign and mail
back to me in the envelope I have provided. You do not need to put a stamp on
the envelope. This form is to let me know you received the letter and whether or
not you will be able to call me.
Notice of Appointment-Please Call Reviewer
SSA-9303 (2-2012)

If you have any questions, please call me at my office between 8:00 a.m. and 4:00
p.m., Monday through Friday. My toll-free number is 1-800- ______. Thank you for
your help.

Sincerely,

Social Insurance Specialist
Enclosures

Notice of Appointment-Please Call Reviewer
SSA-9303 (2-2012)

PRIVACY ACT AND PAPER REDUCTION ACT NOTICE
COLLECTION AND USE OF INFORMATION
Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect the
information contained on this form. We will use the information you provide us to determine
your eligibility to the Medicare prescription drug plan. Your responses are voluntary. However,
failure to provide all or part of the requested information correctly could result in an increase,
decrease or termination of your subsidy level.
HOW THE INFORMATION IS USED
We rarely use the information provided on this form for any other purpose other than the
reasons explained above. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency
in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
See revised
records (e.g., to the Government Accountability
Office and Department of Veterans’
Privacy Act
Affairs);

Statement below.
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of Social Security programs.
We may also use the information you provided in computer matching programs. Matching
programs compare our records with records kept by other Federal, State and local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally funded and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice,
entitled, Medicare Database (MDB) File, 60-0321. The notice, additional information regarding
this form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement – This information collection meets the requirements of 44
U.S.C § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments on our time estimate above to: SSA, 6401 Security
Blvd., Baltimore, MD 21235-6401.

Notice of Appointment-Please Call Reviewer
SSA-9303 (2-2012)

FORM APPROVED
OMB No. 0960-0707

ACKNOWLEDGEMENT FORM
(RETURN THIS SHEET IMMEDIATELY)
_________________________________________________________________________________
Beneficiary’s Name

1. Will you be available at the time requested?

□ Yes

_______________________
Beneficiary’s SSN

□ No

2. What telephone number can we use to reach you, including area code? (

)____________________

3. If you will not be available at the time requested, we can reschedule your appointment. If you would
like to reschedule, please let us know when you will be available at that number.
_______________________________________________________________________________
4. Is your address shown correctly on this letter? □ Yes □ No
If “NO”, please show the appropriate address below:
__________________________________________________________________________________
__________________________________________________________________________________
5. If you need assistance with the telephone interview due to a hearing impairment, please
check/complete the appropriate box(es) shown below:
□ I am deaf or hard of hearing. I will have a person to assist me with this telephone interview.
His/her name is _____________________. He/she is my __________________ (indicate
your relationship).
□ I am deaf or hard of hearing. SSA may call me with the assistance of a Telephone State
Relay System operator.
6. If you need assistance with the telephone interview due to language problems, please
check and complete the appropriate box(es) shown below:
□ I need a language interpreter. I speak__________________ (indicate language).
□ I will provide a qualified language interpreter for this telephone interview. His/her name is
_____________________. He/she is my __________________ (indicate your relationship).
(Your interpreter should be 18 years of age or older).
□ I want SSA to provide a qualified language interpreter for this phone interview at no cost to
me.

Sign
here

►

____________________________________________________________________
(SIGNATURE of Beneficiary or Payee if applicable)

______________________
Date

QRA_______________________

Notice of Appointment-Please Call Reviewer
SSA-9303 (2-2012)

Privacy Act Statement
Collection and Use of Personal Information

Section 1860 D-14 of the Social Security Act of the Social Security Act, as amended, allows us
to collect this information. We will use the information you provide to determine your continued
eligibility for help paying your share of the cost of a Medicare Prescription Drug Plan.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could result in a change or termination of your subsidy.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0321, entitled Medicare Database.
Additional information about this and other system of records notices and our programs are
available from our Internet website at www.socialsecurity.gov or at your local Social Security
office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.